Case studies are going make me pull my hair out!! Help..

Daytonite, BSN, RN · Nov 23, 2008

case studies require you to examine the evidence before you and think of the reasons why each thing would be elevated or decreased and compare it with the information you were given and how that information affected or influenced those outcomes.

69 year old female, having semielective mitral valve replacement. has had long-standing mitral stenosis, complicated by two embolic strokes. she recieved a mitral commissurotomy 10 years ago. currently on coumadin therapy. no current bleeding history.

lab values

hct 35%

platelet count 185,000/mm3

bleeding time 5.6 minutes

aptt 43sec (control 33 seconds)

pt 25.6sec (control 11.6 seconds)

thrombin time - normal

is she ready to have her mitral valve replacement?

this question is asking you if it is safe for the patient to go to surgery and be cut upon. the worry is that you don't want her to hemorrhage when she is cut, so look at the platelet count, bleeding time, aptt, pt and thrombin time. if they are elevated above normal levels she will be at risk to hemorrhage and the doctor will not want to do surgery on her. they need to be at normal levels or she is not ready to have her mitral valve replacement.

platelet count - normal 150,000-450,000/mm3 (hers: 185,000/mm3) -
bleeding time - normal 2.5 to 10 minutes (hers: 5.6 minutes)
aptt (activated partial thromboplastin time) - normal control 25 to 39 seconds [hers: 43sec (control 33 seconds)]
pt (prothrombin time) - normal control 11.0 to 12.5 [hers: 25.6 sec (control 11.6 seconds)]
thrombin time - normal
my reference:
davis's comprehensive handbook of laboratory and diagnostic tests with nursing implications
, 2nd edition, by anne m. van leeuwen, todd r. kranpitz and lynette smith

i say, start working on her or checklist. this lady is going to the or! yes, she is ready to have her mitral valve replacement.

52 year old female suffering from painful joints. was placed on gold therapy to allivate arthritic joint pain. one week later she is complaining of a sore throat, headache, chills. over the next 24 hours she deteriorated rapidly and began experiencing mild shock. here admitting cbc was as follows:

hgb 13.2

hct 40%

wbc 0.6x10 (9/l)

neutropenia ( absence of neutrophils)

lymphocytosis (87% of her wbcs are lymphocytes)

platelets are of normal number.

gold is a heavy metal. when patients are given gold as a treatment a baseline cbc is drawn and any side effects generally take several weeks to appear with affects on the mucus membranes being the most prominent (the sore throat). thrombocytopenia is also one of the side effects as well, but this patient's platelets are normal, so gold poisoning is not the problem here. i think you need to read a physiology book on the various functions and life cycles of the different wbcs. you are told that this patient has "

painful joints

" and then that she was "placed on gold therapy to alleviate

arthritic joint pain

". there is only one painful arthritic joint disease i know of that is treated with gold salts that would use up all of a patients neutrophils. it is a chronic inflammatory condition of the immune type that would use up wbcs and that is

rheumatoid arthritis

.

Jpkneal20 · Nov 24, 2008

Thank You sooo much!! I think I have been beating around these too much without stopping to think.

So on study #2- The Neutropenia is due to the gold therapy, But would gold therepy also cause Lymphocytosis?

The biggest problem I am having with this is that her blood count is super low and the only cell seen in the periperal blood is the Lymphocyte. (not a blast, a mature lymph). The low count makes me think its something else, but the Lymphocytosis makes me think CLL.... Humm.....I have to keep thinking about this one.

I REALLY need to buy that book you mentioned.

Thank you!!

Daytonite, BSN, RN · Nov 24, 2008

thank you sooo much!! i think i have been beating around these too much without stopping to think.
so on study #2- the neutropenia is due to the gold therapy, but would gold therepy also cause lymphocytosis?
the biggest problem i am having with this is that her blood count is super low and the only cell seen in the periperal blood is the lymphocyte. (not a blast, a mature lymph). the low count makes me think its something else, but the lymphocytosis makes me think cll.... humm.....i have to keep thinking about this one.
i really need to buy that book you mentioned.
thank you!!

no. the neutropenia is due to rheumatoid arthritis (ra). the gold therapy has nothing to do with any of the lab results. ra is a chronic inflammatory disease which has the immune response constantly activated. the immune response (https://allnurses.com/forums/f50/histamine-effect-244836.html) is using up all of her wbcs! when someone has a chronic inflammation like ra the inflammation response never stops. it is ongoing. neutrophils are the mature wbcs. well, as in any major war effort, they were put into service when the war started, gone and sacrificed--a long time ago. her poor immune system struggles to replace them. she will never have mature neutrophils again because her body is constantly in a state with inflammation going on in her joints. her immune system literally scrounges for every measly wbc it can find so it is down to using kids, the immature wbcs. as new wbcs are formed in her body they are pushed into the war before they even have time to mature and become neutrophils--which is why i call them kids. it is possible that some of her symptoms are side effects of the gold salts, but the low wbcs are because of the ra.

you can get lab test information online at these websites:

medicine net procedures & tests a to z index http://www.medicinenet.com/procedures_and_tests/article.htm
web md index list of tests http://www.webmd.com/a_to_z_guide/medical_tests.htm
lab tests online http://www.labtestsonline.org/

Jpkneal20 · Nov 24, 2008

thank you. That all makes perfect sense. I seriously must work on my critical thinking skills.

Thanks for the links too!